complete solution
Which of the following demonstrate that further teaching is required to prevent an
infection related to being catheterized? (Select all that apply.)
A) An elderly female carries her urinary drainage bag like a purse under her arm as she
ambulates.
B) A patient drinks an entire pitcher of water over the period of one day.
C) As a patient is being transferred in a wheelchair, he places the drainage bag in his
lap.
D) The NAP places a patient's drainage bag on a lowered side rail or on the floor.
E) A female patient keeps her catheter secured to her thigh with tape.
A, C, D
Which of the following are true regarding the impact of aging related to urinary
elimination? (Select all that apply.)
A) The elderly are better able to concentrate urine than the middle-aged adult.
B) Aging can affect continence if the patient experiences impaired mobility or decreased
muscle tone.
C) The elderly are less likely to experience urinary frequency than middle-aged adults
because they tend to drink less.
D) The elderly are at increased risk for urinary tract infection because of retained urine
in the bladder.
E) It is part of the normal aging process for elderly patients to become incontinent.
B, D
During change-of-shift report the nurse states that a patient has early renal failure and
to be alert to this when administering medications. Why would this be a concern?
A) The kidneys assist in the detoxification of medication metabolites.
B) The patient may not be able to absorb all of the medications.
C) The bladder acts as a filter to remove wastes and form urine.
D) The kidneys are the primary site for medication metabolism.
A
The nursing instructor is reviewing the renal system and urinary catheterization with her
students. Which statement, if made by a nursing student, indicates that further
instruction is needed?
A) "The urinary tract is considered to be sterile."
B) "The nurse may use clean technique to insert an indwelling catheter."
C) "The urge to void is felt when the bladder contains 150 to 200 mL in an adult."
D) "The minimum average hourly urine output is 30 mL."
B
A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis
(blood clots). She comes to the clinic complaining, "I have to get up all night to go to the
bathroom, and I think my urine looks orange!" What is the nurse's best response?
A) "It sounds like you may have a urinary tract infection."
B) "Your high blood pressure is adversely affecting your kidneys."
, C) "Have you tried to restrict your fluid intake?"
D) "What medications are you taking and when?
D
A 68-year-old female patient is admitted for knee replacement surgery with an expected
hospital stay of 2 weeks. She has no known allergies. The health care provider has
ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter
should the nurse choose?
A) 14 French, 5-mL balloon, latex catheter
B) Coude catheter
C) 16 French plastic catheter
D) 18 French, 5-mL balloon, latex catheter
E) 8 French, 3-mL balloon, latex catheter
F) 16 French, 30-mL balloon, silicon catheter
A
A health care provider has ordered an indwelling catheter to be inserted to bedside
drainage. Which of the following is NOT an expected indication for Foley
catheterization?
A) Preoperative status.
B) To determine urinary retention.
C) To obtain accurate urinary output in a critically ill patient.
D) To allow a pressure ulcer on the coccyx to heal in a patient with urinary incontinence.
B
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of
the following explanations regarding anchoring of the catheter, would be most accurate?
A) An indwelling catheter tube is secured to a female patient's abdomen to prevent
accidental dislodgment.
B) An indwelling catheter tube is secured to the male's inner thigh with a strip of
nonallergenic tape or a commercial tube holder.
C) It is important to anchor the catheter tubing to minimize the risk for urethral trauma,
bladder spasms from traction, and to prevent accidental dislodgment.
D) When securing the catheter tubing, slack in the catheter should be avoided to
prevent movement and possible tissue injury.
C
A nurse inserting an indwelling Foley catheter in a female patient advances the catheter
and obtains clear yellow urine. What is the next action the nurse should take?
A) Inflate the balloon with the prefilled syringe of sterile water in the balloon port.
B) Pull gently back on the catheter approximately 1 inch or until resistance is met.
C) Advance catheter another 1 to 2 inches and inflate balloon.
D) Ask patient to bear down as if to void.
C
The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no
urine return even though her bladder is distended. What action should the nurse take at
this time?
A) Remove the catheter and have another nurse attempt to catheterize the patient.
B) Leave the catheter in vagina as a landmark and insert another sterile catheter.
C) Remove the catheter and reinsert into the urethra. The nurse may straighten the